Lisa L. is an 18-year-old female, who had been complaining of neck pain for the past six years. The patient reports that, six years ago, when she woke up, she suddenly realized that her neck jerked to the left. The jerk happened very often; her neck would jerk two or three times every 5-10 minutes. The jerk was involuntary and occurred more frequently especially when she was tired or under stress. However, if she had a good night’s rest, felt energized, and focused on something (e.g. her favorite sports), she would not experience the sudden, involuntary neck movements. Only when she sat still, did her neck start to jerk.

Lisa’s neck muscle always feels very tight, and the tightness can be very painful. She has been to many doctors and has tried everything, such as physical therapy and multiple medications, without any improvement. She therefore came to me for evaluation and treatment. Upon physical examination, I noted that the left side of the patient’s sternocleidomastoid muscle had hypertrophied. It felt like a thick rope on the left side of her neck. I also noted that other muscles had undergone hypertrophy: the levator scapular and splenius capitis at the cervicals. Throughout the entire physical examination, there was no jerk or involuntary contraction on the left side of the patient’s neck.

What Lisa is suffering from is called cervical dystonia, which is the most common form of focal dystonia. Cervical dystonia is characterized by abnormal and spasmodic squeezing of the muscle that leads to muscle contractions in the head and neck area. The movements are involuntary and are sometimes very painful, causing the neck to twist repetitively, resulting in abnormal posture. Overall, this may affect a single muscle, a group of muscles, such as those in the arms, neck, and legs, or even the entire body. Patients with dystonia often have normal intelligence and no associated psychiatric disorders.

The causes of cervical dystonia are currently unknown. There are two types of cervical dystonia:

Primary cervical dystonia: This type of cervical dystonia is not related
to any identifiable, acquired disorders affecting the brain or spinal cord such
as stroke, infection, tumor, or trauma. In some cases, primary cervical dystonia
is genetic, caused by abnormal genes such as dystonia DYT1. However,
because not all carriers of the DYT1 gene develop cervical dystonia, it
is likely that other genes or environmental factors may play a role in the
development of cervical dystonia.

Secondary cervical dystonia: Unlike primary cervical dystonia, secondary
cervical dystonia has obvious causes such as stroke, tumor, infection in the
brain or spinal cord, traumatic brain injury, toxins, birth defect, etc. There
may be a period of months between the injury and the onset of the dystonia.

Tests and diagnosis:

The first step when diagnosing cervical dystonia is to determine if any of the causes that may lead to secondary dystonia are evident. The following tests may be used to screen and/or diagnose for secondary cervical dystonia:

1.Toxins and infections screening: blood or urine samples will confirm the presence of toxins and infections.

2.Tumor screening: an MRI will identify and visualize tumors of the brain or spinal
cord.

3.Genetic testing: can be used to identify DYT1, which is critical to the diagnosis
of primary cervical dystonia.

Botox injections can usually stop the muscle spasms by blocking acetylcholine, relieving the symptoms for approximately three months. Very experienced doctors should administer the Botox injections. If Botox is used for more than a one-year period, it will gradually become less effective because the patient’s body will begin producing auto-antibodies against it.

Other treatments:

In some severe cases, surgery may be an option. Surgery is the last resort and is used to selectively denervate the nerve supplying the muscle.

Another treatment option is deep brain stimulation. This involves implanting an electrode in the brain connected to a stimulated device in the chest that generates an electrical pulse. These electrodes will temporarily disable nerve activities by damaging
small areas of the brain.

Chinese medicine:

According to traditional Chinese medicine, cervical dystonia is caused by excessive liver wind. The liver controls the movement of all tendons, muscles and joints in the human body. Excessive liver wind overstimulates the tendons, muscles and joints, constantly activating the muscles. We use the following methods to treat our cervical dystonia patients.

Acupuncture

The principle acupuncture treatment used to treat cervical dystonia reduces the excessive liver wind and thereby decreases the activities of the tendons, muscles and joints. The acupuncture points are along the meridians of the liver and gall bladder, such as the Feng Chi and Tai Chong points.

In addition, because patients with cervical dystonia have abnormal head and neck movements, acupuncture must also be used along the Du meridian, which controls head movement. The Du meridian supplies the entire brain. If the energy of the Du meridian is excessive, the entire head will move abnormally. Therefore, the acupuncture treatment should also include the Da Zhui and Hou Ding points from the Du meridian. These points will adjust and regulate the Du meridian, the yang, activate the tendon function, and balance the input and output of the energy of the Du meridian.

The acupuncture treatment should also include the Xin Shu, a direct outlet acupuncture point from the heart and the Shen Shu, a connecting point from the kidney. Sheng Men, Tai Xi and the points listed above are involved in the circuitry of the heart and kidney, and will decrease the fire surrounding these organs, keeping the yin and yang in harmonious balance. Some local points in the neck and head such as Tian Chuang, Tian Rong, Tian Ding, and Fu Tu, should also be used for their localized calming functions.

This combination of local and distal acupuncture points will greatly decrease the symptoms associated with cervical dystonia.

Moxibustion:

Moxa is a Chinese herb similar to cigarette to warm certain points in the human body. We suggest to use the following device to moxa the neck sternocleidomastoid muscle for 30 minutes. Patients should learn how to use it before you use for yourself.

Guasha (Scrape) :

Following the length of sternocleidomastoid muscle, use the Guasha plate to scrape down 30 times then up 30 times, 5 sessions per day.
The patient was treated with acupuncture at the above points for approximately two months, three times a week. After the last treatment, the number of neck contractions had significantly decreased. Now, she only experiences mild neck jerks and contractions, allowing her to perform her daily activities in a normal manner.

Tips for acupuncturists:

Acupuncture cannot treat all forms of cervical dystonia. The milder the disease, the better the treatment results. Physicians should find the cause if the patient is suffering secondary cervical dystonia.

Using heating pads and massages after the acupuncture treatment increases its effectiveness.

Dr. Jun Xu went to Leprosy village in 2013, 2014 and 2016, soon he will go to the leprosy village on March 31, 2017.

In 2013, there was no a single room being used for treatment in the leprosy village, Dr. Xu and his team had to use a tent. The temperature was around 125 Fahrenheit degrees.

The leprosy patients were waiting for their turn to be attended. Dr. Jun Xu saw about 200 patients a day.

Typical leprosy patient:
Early Stages
Spots of hypopigmented skin- discolored spots which develop on the skin
Anaesthesia(loss of sensation) in hypthese opigmented spots can occur as well as hair loss
“Skin lesions that do not heal within several weeks of and injury are a typical sign of leprosy.” (Sehgal 24)

Progression of disease

“Enlarged peripheral nerves, usually near joints, such as the wrist, elbow and knees.”(Sehgal 24)
Nerves in the body can be affected causing numbess and muscle paralysis
Claw hand- the curling of the fingers and thumb caused by muscle paralysis
Blinking reflex lost due to leprosy’s affect on one’s facial nerves; loss of blinking reflex can eventually lead to dryness, ulceration, and blindness
“Bacilli entering the mucous lining of the nose can lead to internal damage and scarring that, in time, causes the nose to collapse.”(Sehgal 27)
“Muscles get weaker, resulting in signs such as foot drop (the toe drags when the foot is lifted to take a step)”(Sehgal 27)

Long-term Effects
“If left untreated, leprosy can cause deformity, crippling, and blindness. Because the bacteria attack nerve ending, the terminal body parts (hands and feet) lose all sensations and cannot feel heat, touch, or pain, and can be easily injured…. Left unattended, these wounds can then get further infected and cause tissue damage.” (Sehgal 27)
As a result to the tissue damage, “fingers and toes can become shortened, as the cartilage is absorbed into the body…Contrary to popular belief, the disease does not cause body parts to ‘fall off’.” (Sehgal 27)

Every year, Dr. Jun Xu and his team bring around $300,000 worth of medicine donated from his team members and Americares in Stamford, CT to treat the leprosy and other patients in Senegal and Guinea Bissau. http://www.americares.org/, in 2017, his team also received medicine donation from Direct Relief in California, https://www.directrelief.org/.
Dr. Jun Xu and his team finally established a clinic in the leprosy village, one building for the clinic, and another building for the living of doctors and nurses.

Leprosy village people were celebrating the opening of the clinic.

There are 8 wards, which could hospitalize the patients if it is medically necessary.

Dr. Jun Xu’s team usually stay in Senegal for 10 to 14 days, these are the foods his team brought from US in order to keep them health and safe. They do not dare to eat street food.

The above are the coolants contained food Dr. Jun Xu’s team brought from US

Dr. Jun Xu and his team from US in 2006.
If you are interested in joining Dr. Jun Xu’s team or donating to his work in Senegal, please address your check payable to AGWV, and send to
Jun Xu, MD, 1171 E Putnam Avenue, Riverside, CT 06878, USA.
Dr. Xu promises that all your donation 100% will go to Senegal and his team will nerve use a penny from your donation. You will receive the tax deductible receipt. Any amount is a great help for Africa patients.
For more info, please visit our websites at
http://www.drxuacupuncture.co/ and http://www.africacriesout.org/

News Letter, Vol. 7 (3)

Jun Xu, M.D. , Peter Zheng, M.D.
www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Why did Tiger Woods receive PRP treatment for his knee and ankle pain?

A few years ago Tiger Woods was in the center of media, all his wrong doing such as extra-marital affairs, car crashes, voicemails to girlfriends, etc. attracted many eyeballs. He was also accused of using human growth hormone. In an interview, Woods explained that he was actually receiving PRP therapy with excellent result for his knee pain. (http://abcnews.go.com/Health/Technology/tiger-woods-admits-platelet-rich-plasma-therapy/story?id=10303312)

“I had PRP, platelet-rich plasma treatments, and basically, what that is, is they draw blood from your arm, spin it in a centrifuge, and take the plasma out and insert it into the injuries. Well, as you all know, in 2008, I blew out my ACL. And part of my reconstruction of my LCL wasn’t reacting properly. It was a little bit stuck, and so I had the PRP injection into my LCL.

And then, in December, I started to train, started running again, and I tore my Achilles on my right leg. And I then had PRP injections throughout the year…And did everything I possibly could to heal faster so I could get back on the golf course, you know, through the PRP injections.”

Did the PRP help Woods?

So, how did Woods do after the PRP injections in December of 2008? Actually, Year 2009 was one of the best years of his career. In the 17 events he played in, he made the cut in 16 of them. He won six of the events, finished second in three others, and finished in the top 10 in all but three. He earned over $10 million on the tour alone, and was given the following awards that year:

PGA Tour Player of the Year

PGA Tour Leading Money Winner

Vardon Trophy

Byron Nelson Trophy

FedEx Cup Champion

Many famous athletes — including Tiger Woods, tennis star Rafael Nadal, and several others, such as Fred Couples, Alex Rodriguez, Tracy McGrady, Chris Canty, Kobe Bryant, and Cliff Lee, have received PRP for various problems, such as sprained knees and chronic tendon injuries. These types of conditions have typically been treated with medications, acupuncture, physical therapy, or even surgery. Many athletes have credited PRP with their being able to return more quickly to competition.

The American Journal of Sports Medicine, Jun 6, 2016 , published an article “The Effectiveness of Platelet-Rich Plasma in the Treatment of Tendinopathy: A Meta-analysis of Randomized Controlled Clinical Trials.” A total of 18 studies (1066 participants) were included. Eight studies were deemed to be at low risk of bias. The most significant outcomes in the PRP groups were seen in those treated with highly cellular leukocyte-rich PRP (LR-PRP) preparations. The authors concluded ”There is good evidence to support the use of the injection of LR-PRP under ultrasound guidance in tendinopathy. Both the preparation and intratendinous injection technique of PRP appear to be of great clinical significance. “ (http://www.ncbi.nlm.nih.gov/pubmed/27268111)

Even though PRP has received extensive public attention, there are still myths about it, such as:

What exactly is platelet-Rich plasma?
How does it work?
What conditions are being treated with PRP?
Is PRP treatment effective?

What Is Platelet-Rich Plasma (PRP)?

As you know, blood contains mainly liquid (plasma) and small solid components (red cells, white cells, and platelets.) The platelets are best known for their importance in clotting blood. However, platelets also contain hundreds of proteins called growth factors which are very important in the healing of injuries, such as synthesis of collagen, growth of cartilage, production of tendon and fibers, and induction of blood vessels, etc.

PRP is plasma enriched with high concentration of platelets and growth factors — can be 5 to 10 times greater (or richer) than usual by PRP centrifuge procedure. Then the increased concentration of platelets is injected to the injury sites of human body. The following figures explained how the PRP is made from.

Fig. 2. https://french.alibaba.com/

How Does PRP Work?

Although it is not exactly clear how PRP works, many researches have shown that the increased concentration of growth factors in PRP can potentially speed up the healing process.

Fig. 3. http://www.nfinders.com/img/product/product_img1_1_1.jpg

To speed healing, PRP is carefully injected into the injured area. For example, in Achilles tendonitis, a condition commonly seen in runners and tennis players, a mixture of PRP and local anesthetic can be injected directly into the heel cord. Afterwards, the pain might be reduced and the injured tissue might quickly heal within one or two months.

What Conditions are treated with PRP? Is It Effective?

Research studies are currently being conducted to evaluate the effectiveness of PRP treatment. Many conditions are treated with PRP, and showed good results. The following figure indicate the areas of PRP treatment

1. Chronic Tendon Injuries

PRP is most effective in the treatment of chronic tendon injuries, especially tennis elbow, rotator cuff , bicipital tendonitis, wrist tenosynovitis , and iliopsoas tendonitis. The use of PRP for other chronic tendon injuries — such as chronic Achilles tendonitis or inflammation of the patellar tendon at the knee (jumper’s knee) showed strong evidence that is clinically very effective.

Fig. 5. http://www.podiatrytoday.com/files/pt1114ortho3.png

2. Arthritis

Research has being done to evaluate the effectiveness of PRP in the treatment of the arthritis. The preliminary data supports PRP is an excellent option to treat different osteoarthritis, such as knee, shoulder, hip and hand.

3. Acute Ligament and Muscle Injuries

Much of the publicity PRP therapy has received has been about the treatment of acute sports injuries, such as ligament and muscle injuries. PRP has been used to treat professional athletes with common sports injuries like pulled hamstring muscles in the thigh and knee sprains. Recently Kobe Bryant went to Germany for PRP treatment. http://grantland.com/features/kobe-bryant-dr-chris-renna-regenokine-knee-treatment/. All the clinical data indicated it might work on the acute sport s injury.

4. Surgery

More recently, PRP has been used during certain types of surgery to help tissues heal. It was first thought to be beneficial in shoulder surgery to repair torn rotator cuff tendons. However, the results so far show little or no benefit when PRP is used in these types of surgical procedures.

Surgery to repair torn knee ligaments, especially the anterior cruciate ligament (ACL) is another area where PRP has been applied. At this time, there appears to be some benefit from using PRP in this instance.

5. Fractures

PRP has been used in a very limited way to speed the healing of broken bones. So far, it has shown no significant benefit.

Conclusion

Treatment with PRP opened a new way to cure your pain. There is much evidence to support this new technology. For all the acute and chronic tendonitis, osteoarthritis, and other pain diseases, we are comfortable to treat with PRP. We have already equipped with state of the art instruments to embrace this new wave. We also received intensive training to perform this new therapy. You are welcome to give us a call to discuss about the benefits and side effects regarding PRP treatment.

Acupuncture and physical therapy are good therapeutic methods before you try PRP treatment. If you tried all the non-invasive treatments, PRP might be your next option.

The risks associated with PRP are minimal: There may be some pain at the injection site, but the incidence of other problems — infection, tissue damage, nerve injuries — appears to be no different from that associated with cortisone injections.

By the way, please be advised that few insurance plans provide even partial reimbursement.

Martha T. is a 50-year-old woman with a long history of diabetes. Approximately two months before consulting me, she felt a slight pain in her right shoulder when she tried to lift a heavy object. Though the pain was not severe for the first few weeks, she gradually noticed a decrease in the mobility and function of that shoulder, coupled with more severe pain. After the incident, she had trouble lifting her arms for tasks such as combing her hair and dressing with ease, especially when putting clothes on her right arm or fastening her brassiere. Hoping the pain would go away, she did not consult a doctor.

When the pain became too severe, she came to me. By physical examination, I noted that there was moderate tenderness at the right frontal and posterior shoulder. Through palpation, I noted tenderness in her upper arm and lateral elbow. She had difficulty raising her right shoulder up to her head and with movements that crossed the body’s middle line. The pain was constant and she was unable to sleep on the right side of her body. Her right arm was weak due to the pain. There was no numbness or a tingling sensation.

This usually occurs after the age of 40, and about 20% of patients who suffer from this disorder have a history of diabetes and most of them have also been involved in some form of accident. When these patients begin to feel shoulder pain, they try to compensate by limiting the normal range of motion in the injured shoulder. Unfortunately, this makes some normal tasks such as brushing the hair, dressing, reaching for objects above the head, etc., more difficult. By this stage, the patient usually realizes it is necessary to seek medical treatment for the condition.

Frozen stage: The pain may begin to diminish during this stage. However, the shoulder becomes stiffer and the range of motion decreases noticeably, which causes the patient to avoid extreme movements that exacerbate the pain during this phase. Usually lasts from six weeks to nine months.

Thawing stage: The shoulder movement gradually returns to normal and the pain lessens. Lasts from five months to two years.

Though the causes of frozen shoulder are still unclear, these are some noted possibilities:

Injury resulting from surgery or any traumatic accident. Most patients have a history of an injury that causes pain and causes the patient to decrease his/her range of movements.

Diabetic patients have a tendency to have frozen shoulder. In those patients who are diabetic (about 20%), this condition worsens the symptoms.

Autoimmune, inflammatory, and any procedures that immobilize the shoulder will increase the chances of frozen shoulder.

Western medicine treatments:

Anti-inflammatory medications: The use of anti-inflammatory medications such as ibuprofen, naproxen, etc. However, these oral medications are not a very effective treatment.

Corticosteroid injection: Using a corticosteroid (i.e. 40 mg of Kenalog and 5 cc of 1% lidocaine injected directly into the shoulder bursa) will greatly decrease the intensity of the pain. However, there are some side effects of corticosteroid injections such as blood sugar elevation, fragile shoulder tendons, osteoporosis, etc. I usually do not recommend using corticosteroid injections unless it is absolutely necessary (i.e. when there is severe pain, largely decreased range of motion, and handicapped daily activities).

In some cases, surgery may be necessary. There are two common types of surgery used to treat frozen shoulder:

Manipulation under general anesthesia: forces the shoulder to move. This process can unfortunately cause the capsule to stretch or tear.

Shoulder arthroscopy: The doctor makes several small incisions around the shoulder capsule. A minute camera and instrument are inserted through the incision and the instrument is used to cut through the tight portion of the joint capsule. Often, manipulation and arthroscopic surgeries are used together and many patients have good results form this type surgery.

Physical Therapy Treatment for Frozen Shoulder:

Physical Therapy treatment generally begins in the first stage of the “frozen shoulder” progression. Upon initial PT evaluation of the effected shoulder, the therapist will begin with gentle passive and active range of motion activities within the patient’s pain tolerance. The primary goal in stages 1 and 2 of the frozen shoulder progression is to reduce pain and begin to regain normal joint motion. Passive stretching of the shoulder in all planes and manual joint mobilization techniques are indicated. Pain relieving modalities such as heat, electric stimulation, and short-wave diathermy can be used when it is at the therapist’s disposal. In addition, basic postural re-education exercises such as scapular retraction and pectoral stretching should be introduced.

Fig. 2

Fig. 3

Fig. 4

As the patient progresses from the “freezing” stage of the condition, more aggressive joint mobilization and stretching techniques are introduced to regain full motion of the shoulder joint. This stage can be painful at times, but it is necessary for long term results and return of normal function. Therapeutic exercises (shoulder elevation, rotation, scapular retraction against resistance, etc.) are progressed to allow for shoulder stabilization within the new ranges of motion achieved with stretching and joint mobilization.

During the final stage of the frozen shoulder progression, the therapist will introduce functional activities to ensure that the effected shoulder is prepared for daily tasks. Pain level should be decreased at this point in treatment.

Low back pain, spasm of the gastrocnemius, hemorrhoids, constipation, beriberi

10

Wai Guan

SJ 5

See table 5-1/Pic 5-3

See table 5-1

11

He Gu

LI 4

See table 3-1/Pic 3-4

See table 3-1

12

Qu Chi

Fig. 5

Fig. 6

Fig. 7

Fig. 8

To treat Martha, I applied the heating pad to her right shoulder for approximately 20 minutes. This increased the flexibility of the tendon underneath. Then, I inserted the needles into the above acupuncture points. After 30 minutes of acupuncture treatment, I gave her a deep massage, and she was told to raise her shoulder and perform other range of motion exercises. The patient underwent my treatment for a total of 10 visits. Afterwards, she reported that her right shoulder pain and range of motion had improved greatly.

Tips for acupuncturists:

Instruct the patient to sit down and relax. First, insert the needle into the Qu Chi tips toward to the shoulder about 1.5 inches deep, causing the energy to transmit up to the shoulder. Then insert the needles into the points of Jian Yu, Jian Zhen, Jian Liao, and Tian Zhong. Insert the needle into Tiao Kou so that it penetrates to Cheng Shan. During the treatment, scratch the handles of needles, and make sure the patient feels this energy sensation from the needle tips spreading to the shoulder.

Tell the patient to slowly raise his/her arm up to the head, and move the arm around. Usually, the patient will feel instant relief from the pain.

Tips for patients:

Do range of motion exercises for 20 minutes every morning taking a hot bath or shower. The hot water increases the blood circulation and energy flow and will allow for the best range of motion and the least pain when doing these exercises.

Purchase a heating pad and apply it to the shoulder for 20 minutes. Do the range of motion exercises again.

The main goal is to increase the range of motion of the shoulder. The second goal is to decrease the pain in the shoulder.

Try to get an acupuncture treatment as soon as possible; do not wait. Without treatment, it may take a few years for natural recovery, and in some cases range of motion will never fully return.

Sandy, a 45 year-old woman, complained of bilateral hand and wrist pain on-and-off for many years. Recently for a month now, she felt both hands had constant pain and were tender, warm and swollen. She woke up with morning stiffness that may last for hours and felt firm bumps of tissue under her both forearm accompanied with fatigue, mild fever and gradually weight loss. She visited her PCP and was given naproxen to reduce her inflammation and pain, however, she felt no improvement. She was referred to a rheumatologist, who ordered x-ray images and rheumatoid factor test. Both were positive for Rheumatoid Arthritis, therefore, the diagnosis was confirmed. The patient was given methotrexate and felt better for morning stiffness and swelling, however, she had many side effects, such as, nausea, vomiting, hair loss, etc. Because of above complaints, she came to me for evaluation and treatment.

Rheumatoid Arthritis (RA) is a chronic, long-term disease that causes pain, stiffness, swelling and limited motion and function of many joints. While RA can affect any joint, the small joints in the hands and feet tend to be involved most often. Inflammation sometimes can affect organs as well, for instance, the eyes or lungs. As the disease progresses, symptoms often spread to the knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of your body.

The stiffness seen in active RA is most often worst in the morning. It may last one to two hours (or even the whole day). Stiffness for a long time in the morning is a clue that you may have RA, since few other arthritic diseases behave this way. For instance, osteoarthritis most often does not cause prolonged morning stiffness.

The normal joint structure appears on the above left. On the right is the joint with rheumatoid arthritis. RA causes synovitis, pain and swelling of the synovium (the tissue that lines the joint). This can make cartilage (the tissue that cushions between joints) and bone erode, or wear away.

RA is an autoimmune disease. This means that certain cells of the immune system attack healthy tissues — the joints in RA, cause the inflammation in the synovium, the tissue that lines the joint. Immune cells release inflammation-causing chemicals. These chemicals can damage cartilage (the tissue that cushions between joints) and bone.

Rheumatoid arthritis affects the wrist and the small joints of the hand, including the knuckles and the middle joints of the fingers.

Fig. 3 RA Hand Deformity www.eastlady.cn

Rheumatoid arthritis signs and symptoms may vary in severity and may even come and go. Periods of increased disease activity, called flares, alternate with periods of relative remission — when the swelling and pain fade or disappear. Over time, rheumatoid arthritis can cause joints to deform and shift out of place.

Diagnosis of RA depends on the symptoms and results of a physical exam, such as warmth, swelling and pain in the joints. Some blood tests also can help confirm RA. Telltale signs include:

Anemia (a low red blood cell count)

Rheumatoid factor (an antibody, or blood protein, found in about 80% of patients with RA in time, but in as few as 30% at the start of arthritis)

Antibodies to cyclic citrullinated peptides (pieces of proteins), or anti-CCP for short (found in 60–70% of patients with RA)

Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)

X-rays can help in detecting RA, but may not show anything abnormal in early arthritis. Even so, these first X-rays may be useful later to show if the disease is progressing. Often, MRI and ultrasound scanning are done to help judge the severity of RA.

There is no single test that confirms an RA diagnosis for most patients with this disease. (This is above all true for patients who have had symptoms fewer than six months.) Rather, a doctor makes the diagnosis by looking at the symptoms and results from the physical exam, lab tests and X-rays.

There is no cure for RA. The goal of treatment is to lessen your symptoms and poor function. No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime. The treatment must start as earlier as possible.

A goal of physical therapy is to help make the muscles stronger and the improve the motion of the joints. Warming up painful joints is very important in managing pain and priming the body for more exercise. This can be accomplished with moist heating pads, a whirlpool or warm shower. Following the warm-up, aerobic exercise such as a stationary bike, elliptical, or even arm bike will continue to work the body. Other arthritis friendly options are aquatic exercises, tai chi or yoga routines.

It is important to be flexible with the workout routine, as if after the warm-up and aerobic exercise the joints are still very sore, change to strengthen a body part with less discomfort. However, do not get in a habit of skipping the warm-up and light aerobic exercise if a joint is tender, as often just these two steps will greatly improve how the joint is feeling. Below are a few range of motion and light strengthening exercises to help the hand that can be performed daily.

Good control of RA requires early diagnosis and, at times, aggressive treatment. Thus, patients with a diagnosis of RA should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the disease. Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling, pain and fever. DMARDs have greatly improved the symptoms, function and quality of life for nearly all patients with RA.

Common DMARDs include methotrexate (brand names include Rheumatrex® and Folex®), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Older DMARDs include gold, given as a pill — auranofin (Ridaura) — or more often as an injection into a muscle (such as Myochrysine). The antibiotic minocycline (e.g., Minocin, Dynacin and Vectrin) also is a DMARD, as are the immune suppressants azathioprine (Imuran) and cyclosporine (Sandimmune and Neoral). These three drugs and gold are rarely prescribed for RA these days because other drugs work better or have fewer side effects.

Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” They can target the parts of the immune system and the signals that lead to inflammation and joint and tissue damage. These medications are also DMARDs. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (Rituxan) and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.

The best treatment of RA needs more than medicines alone. Patient education, such as how to cope with RA, also is important. Proper care requires the expertise of a team of providers, including rheumatologists, primary care physicians, physiatrist and physical and occupational therapists. You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications. You likely also will need to repeat blood tests and X-rays or ultrasounds from time to time.

Living with rheumatoid arthritis

It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.

When you feel better, do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.

Acupuncture Treatment:

Acupuncture is an excellent alternative way to treat your symptoms. It has no side effects and can be combined with traditional western medicine to relieve your symptoms. The choice of acupuncture treatment of RA is as following,

Sandy was treated with me for 2 x per week for 8 weeks. I first try to decrease her pain at the joints and body with the points of group 1 and 2 , then, I used the group 3 and 4 points to help her to improve her fatigue and depression, after about 2 month’s treatment, Sandy was put on maintenance treatment program once a week for 4 weeks, and she felt much improved. Her pain scale decreased from 7/10 to 2/10. Her swelling at both hands is much relieved.

Tips for Patients:

1. Multiple Therapies are the best way to treat RA with combination of medicine, PT and Acupuncture.

2. Newer treatments are effective. RA drugs have greatly improved outcomes for patients. For most people with RA, early treatment can control joint pain and swelling, and lessen joint damage.

3. Seek an expert in arthritis: a rheumatologist. Expertise is vital to make an early diagnosis of RA and to rule out diseases that mimic RA, thus avoiding unneeded tests and treatments. A physiatrist who is an expert in RA also can design a customized treatment plan that is best suited for you. Therefore, the rheumatologist, working with the primary care physician and other health care providers, should supervise the treatment of the patient with RA.

4. Start treatment early. Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.

Tips for Acupuncturists:

1. Treat your patients as a whole person and long-term treatment is necessary. You should encourage your patient perform exercise, which will keep your patients’ mobility of hands and other joints.

2. Encourage your patients to have at least 8 weeks treatment. It is very important to have a long-term treatment to achieve the best results.

Helen is a 46 years old female, who complains of pain all over the body for about one year. Her husband lost his job about one year ago and has tried his best to find one. However, he has had no such luck. Helen started to worry about her family financial situation and very often could not sleep well. She always feels sluggish as sleep is not replenishing her energy. She wake up feeling very stressed out and moody and worrying about everything. She gradually developed pain all over the body, feeling tenderness at symmetric points, such as neck, upper back, shoulders, elbows, middle back, low back, hip, knee and calf. The pain is getting worse, now even moderate touch could make her feel pain. She was forced to move out of her house because she was unable to pay her mortgage and moved in an apartment recently. This made her symptom worse, she went to her primary care physician, who checked her blood work, chest x-ray and EKG, all were normal, and prescribed Ambien and pain medication, such as Oxycodone, she felt temporarily relief, however, she had constipation, headache, sometimes diarrhea, felt very tired when waking up. Because the symptoms were getting worse, therefore, she came to me for evaluation and treatment.

Upon examination, she looked very tired and fatigue, spoke with a low tone, she was found to have many tender points along the spine, chest ribs, shoulders, elbows, hips and knees, when she was touched by my fingers.

This patient might have fibromyalgia, a common syndrome, most often occurring in middle age women. Symptoms are long-term, body-wide aches, pains and tenderness. Typically symmetric in the joints, muscles, tendons, and other soft tissues, very often with accompanying fatigue, depression, insomnia, and anxiety.

Causes

The cause is unknown. Possible causes or triggers of fibromyalgia include:

Genetics: the mode of inheritance is currently unknown, but it is common to see patients in one family, especially mother and daughter.

Stress: an important precipitating factor, Fibromyalgia is frequently found with stress-related disorders, such as chronic fatigue syndrome, posttraumatic stress syndrome, irritable bowel syndrome, and depression.

Physical or emotional trauma

Poor sleep.

Among the above possible causes, the most important are stress and poor sleep, stress and poor sleep make a noxious cycle: Stress causes poor sleep, poor sleep enhances stress, both stress and poor sleep make muscles unable to relax, for a long time period, the muscles nerve get chance to relax, then it twists together and forms the tender points and bends, which are symmetric and long term.

Fibromyalgia patients tend to wake up with body aches and stiffness, pain improves during the day and gets worse at night. Some patients have pain all day long. Pain may get worse with activity, cold or damp weather, anxiety, and stress.

Fatigue, depressed mood, and sleep problems are seen in almost all patients with fibromyalgia. Many say that they can’t get to sleep or stay asleep, and they feel tired and stiffness when they wake up.

The new criteria keep the requirements that other causes be ruled out and that symptoms have to have persisted for at least 3 months. They also includes 2 new methods of assessment, the widespread pain index (WPI) and the symptom severity (SS) scale score.

The WPI lists 19 areas of the body and you say where you’ve had pain in the last week. You get 1 point for each area, so the score is 0-19.

This next part is really interesting to me. Instead of looking for a hard score on each, there’s some flexibility built in, which recognizes the fact that fibromyalgia impacts us all differently, and that symptoms can fluctuate.

For a diagnosis you need EITHER:

WPI of at least 7 and SS scale score of at least 5, OR

WPI of 3-6 and SS scale score of at least 9.

Treatment

The goal of treatment is to improve impaired function, help a person mentally and physically cope with the symptoms, and to help relieve pain and other symptoms,

Physical Therapy is aimed at treating the disease consequences of fibromyalgia including pain, fatigue, deconditioning, muscle weakness and sleep disturbances among others.

Modalities such as ultrasound and TENS machines will help reduce localized and generalized musculoskeletal pain in fibromyalgia patients.

Massage is great to reduce muscle tension and spasms which prevent efficient muscle motion. Techniques such a joint mobilizations and deep tissue massage prescribed with other therapeutic interventions such as stretching will help your muscles more effectively.

Physical Therapy consult is very beneficial to address sleeping disturbances affecting about 80% of all patients. Positioning while sleeping and relaxation techniques prior to sleeping can help correct this serious problem.

Fitness machines such as exercise bikes or elliptical machines will improve important measures of cardiovascular fitness, subjective and objective measures of pain. Also improving is subjective energy levels, work capacity along with physical and social activities.

Focusing on core stability will reduce overloading of the muscle system by supporting the muscles of your spine. There is a great impact on conditioning weak muscles for improving postural fatigue and positioning. With a strong core, your body will have a stable, center point.

There is great evidence based research for Whole Body Vibration use on patients with fibromyalgia. A 6-week study published in 2008, in The Journal of Alternative and Complementary Medicine, by Alentorn-Geli et al reports that WBV safely reduces pain and fatigue while also improving physical function in patients with fibromyalgia. Here at Rehab Medicine & Acupuncture Center, we have been using this evidence based device in successfully treating symptoms of fibromyalgia.

Another study looking at the benefits of WBV with fibromyalgia performed by Sanudo et al in 2010 was published in Clinical and Experimental Rheumatology. This study examined women with fibromyalgia performing exercise training 2 times a week along with WBV three days a week compared with an exercise only group over a 6-week period with a focus on strength and quality of life. Significant improvements in all outcomes measured were found from baseline in both groups though additional health benefits were observed with the supplementary WBV.

The second line of treatment is medications, such as antidepressant or muscle relaxant in order to improve sleep and pain tolerance, Duloxetine (Cymbalta), Pregabalin (Lyrica) and Milnacipran (Savella) are very often prescribed.

However, many other drugs are also used to treat the condition, including:

Anti-seizure drugs

Other antidepressants

Muscle relaxants

Pain relievers

Sleeping aids

Cognitive-behavioral therapy is an important part of treatment. This therapy helps you learn how to:

Helen underwent our treatment about 3 months. I first helped her improve her sleep. According to Chinese Medicine, the key factor was sleep, if the patient can have better sleep, her noxious cycle will be broken, and along with her improvement of sleep, her muscles was gradually relaxed and her pain was gradually reduced. She also was encouraged to have physical therapy to improve her functional abilities and join the entertainment activities, she had difficulty playing tennis at beginning, after a few treatments, her performance of tennis was getting better, and after all the treatment for three months, her pain is almost gone and quality of life is much better.

Tips for patients:

Keep a peaceful mood, and you have to realize that your worrying does not take away your stress, but adds stress to you.

Try to get a good sleep nightly, take hot shower before go to bed and avoid TV in order to have a nice sleep routine.

Massage sleep points 5 mins before you go to bed.

Force yourself to attend the entertainment activities

Tips for Acupuncturists:

Try to help patients to have good sleep by selecting Baihui, An Mian, etc.

Try to help patients to have stress reduction by selecting Shen Men, Shen Shu, etc.

Brittany, a sixty-five-year-old woman, experienced on-and-off pain in her shoulder for two or three years, especially upon awakening. The pain was located on the front, sometimes the top, of her shoulder, which made everyday tasks, such as reaching for a high shelf or combing her hair, difficult for her. It also caused swelling of her right shoulder, which became worse when the weather changed, so much so that she told her friends she was a human weathervane. Recently, she began to feel a clicking or grinding sound in the shoulder, and it became increasingly difficult to fall or stay asleep due the pain, which has been increasing for several years.

Brittany was a basketball player in college and sometimes when she shot the ball she felt some pain, but it went away after a day or two. She began taking Tylenol and Advil, which gave some relief, but because she was so occupied with her own business, and because she always assumed the pain would eventually go away, she never made the time to go to a doctor before she came to me.

In my physical exam, I found the deltoid muscle of her right shoulder was atrophied. The right shoulder front, top, and back of the shoulder blade were all tender. When I performed a range of motion test, the flexing in the right shoulder was about 0–120 degrees and her extension was about 0–115 degrees, with pain in the 0–70 degree extension. The grinding, cracking noise that accompanied this extension made the pain in this shoulder feel worse, but I found no signs of arthritis in other joints, including the left shoulder, which was perfectly normal.

Symptoms, Causes, and Diagnosis

There are two main shoulder joints

The glenohumeral joint, which is also called the bone-circuit joint. Here, the typical pain is on the top and back of the shoulder and it sometimes involves pain in the shoulder blade, the scapula, and restricted range of motion.

The acromioclavicular joint. Arthritis can develop where the collarbone meets the shoulder blade (scapula), at the bony prominence on the top of the shoulder blade known as the acromion. The pain is at the top of the shoulder and increases when, for example, the arm is crossed in front of the body to touch the other shoulder, or the arm is raised to comb the hair or take something from a high shelf.

Figure 2.1

There are three principal types of arthritis.

Osteoarthritis, inflammation of the joints, is caused by wear and tear.

Rheumatoid arthritis, an autoimmune disease that is usually a symmetrical inflammation of the joints, especially the shoulder, knee, and other small joints.

Posttraumatic arthritis, which results from injury.

Treatments for Shoulder Arthritis in Western Medicine

Noninvasive Treatments

The first methods to try are the nonsurgical treatments.

Rest

Rest and changing physical activities. The person should avoid any activity that provokes pain.

Compresses

Using hot and cold compresses can be very helpful.

Physical Therapy

Physical therapy and massages. Below are a few exercises that will help strengthen the rotator cuff to allow more fluid motion. Three sets of 10 each should be performed 3 times a week.

Figure 2.2

Figure 2.3

Surgery

If non-surgical treatments do not work, then surgery would be necessary.

Resection arthroplasty is the most common surgical procedure for arthritis of the acromioclavicular joint. Its purpose is to restore the flexible connection between the acromion and the collarbone. A small piece of bone from the end of the collarbone is removed, leaving a space that later fills in with scar tissue.

Total shoulder arthroplasty for glenohumeral joint arthritis. In this procedure, a surgeon replaces the entire shoulder joint with a prothesis.

Hemiarthroplasty, also for glenohumeral joint arthritis. In this procedure, the surgeon replaces the head of the upper arm bone. One joint surface is replaced with an artificial material, usually metal.

I suggest to most of my patients that they try the nonsurgical treatments first. However, if the pain is intolerable and severely restricts sleep, a surgical treatment might be the better of the two options.

Treatments for Shoulder Arthritis in Traditional Chinese Medicine

Acupuncture

When performed appropriately, acupuncture can help with these two types of osteoarthritis.

For glenohumeral osteoarthritis, I use Jian Yu, Jian Liao, Jian Zhen, Quchi He Gu, and also Tian Zhong and Jian Qian. All needles need to be inserted to about 1.5 inches with electrical stimulation for about 30 minutes. The patient must be in a seated position and the electrical stimulation should be as high as can be tolerated.

For acromioclavicular osteoarthritis, it is essential to locate the exact point of tenderness in the front of the shoulder and the AC joint and insert the needle into that AC joint, then the remaining points as in the preceding paragraph. This principle of treatment is called “acupuncture points selection based on the pain location,” aka the specific anatomical location following the pain points.

Table 2.1

Points

Meridian/No.

Location

1

Jian Qian

Extrapoints 23

See Fig 2.4

2

Jian Yu

LI 15

See Fig 2.4

3

Jian Zhen

SI 9

See Fig 2.4

4

Jian Liao

SJ 14

See Fig 2.5

5

Tian Zhong

SI 11

See Fig 2.5

5

Qu Chi

LI 11

See Fig 2.4

7

Wai Guan

SJ 5

See Fig 2.4

8

He Gu

LI 4

See Fig 2.4

Fig 2.4

Fig 2.5

Brittany’s Treatment

Brittany had an X-ray which showed that the cartilage of her right shoulder was wearing out. On the glenohumeral joint there was a loss of joint space and bone spurs were present. She was also given a blood test to rule out rheumatoid arthritis, and it came back negative.

Brittany was advised to avoid lifting anything heavy, to stop using weights, or doing any other upper-extremity exercises, including basketball, if she still played that sport.

If her shoulder was swollen, Brittany was advised to use a cold pad for 15–20 minutes 3 times a day; conversely, if there was no swelling, then she was advised to use a heating pad in the same manner. Acupuncture, physical therapy, and massage were to be tried before any surgery was performed.

Brittany received treatment 3 times a week for 6–8 weeks and her shoulder pain was much relieved. However, I had to advise her that acupuncture cannot change the lost cartilage or remove the clicking, snapping sound. It could decrease the pain, making it improved enough that she would be able to get a good night’s sleep and could prolong the need for surgery. Brittany reported that this was indeed the case after the treatments. For now, her pain has sufficiently diminshed to allow her to go on living her life without having to resort to surgery. [Ed.Supplied an upbeat update that was needed here.].

Tips for People with Shoulder Osteoarthritis

If your shoulder is a normal temperature, always put a heating pad on it twice a day for 30 minutes each time. If it is hot, place a cold pad there for the same amount of time.

After the hot or cold pad, spend 30 minutes a day doing range-of-motion exercises for the shoulder. These will greatly improve your shoulder mobility and decrease the pain.

ROTATOR CUFF TEAR

Matthew P., a 45-year-old man, injured himself after pitching a few baseballs to his son. He felt a sudden onset of right shoulder pain, which was so severe that he could not raise his arm, and this considerably interfered with his daily activities.

When I questioned him, Matthew told me he had experienced this pain on and off for more than six months, but it was mild enough that he did not feel it was necessary to see a doctor. This pain was present both during daily activities and at night, radiating from the front of the shoulder to the side of the arm. It had been steadily worsening, and the injury was exacerbated by the fact that his son had just returned from boarding school two weeks before and they began playing baseball together again. Within those couple of weeks, Matthew’s condition had worsened and he was no longer able to raise his arm to a 90-degree angle.

When I performed the physical examination, I found that his right shoulder was moderately swollen and very tender to the touch at the front and back of the deltoid area. He also had a painful arc of movement between 60 and 120 degrees. I had to help him raise his arm from 60 to 90 degrees, which caused him pain, but once he got it past the 120 degree mark he could do it himself and the pain subsided. I also tried a drop arm test—I lifted his right arm passively up to 90 degrees, then let go—and he had difficulty maintaining the arm at this position on his own.

Based on the above observations, I concluded that Matthew had most likely torn his rotator cuff. This condition has different names: rotator cuff tendonitis, rotator cuff inflammation, shoulder impingement syndrome, rotator cuff bursitis, etc. The most common symptom is that patients experience gradual onset of shoulder pain with difficulty in raising the arms up to 120 degrees. The impingement of the rotator cuff tendons is the most common cause of shoulder pain.

The rotator cuff is a group of tendons composed of four muscles: the supraspinatus, infrapinatus, subscapularis and teres minor. These muscles cover the head of the humerus, and combined with the deltoid muscle, they form the bow of the shoulder. The muscles’ function is to rotate and lift the shoulder.

The acromion is the front edge of the shoulder. It normally sits over and in front of the humeral head when the arm is lifted and in most cases will not rub the tendons of the rotator cuff. However, in some cases, the acromion might wrap or impinge on the surface of the rotator cuff, which causes pain and limits the shoulder movement; this is called impingement syndrome. There are three stages of rotator cuff impingement syndrome:

Stage one: edema or hemorrhage stage. This usually occurs when a patient is under 25 years old. The shoulder shows acute pain, edema or hemorrhage with signs of inflammation. This stage is reversible and surgery is rarely used to treat the condition.

Stage two: fibrosis and tendonitis stage. The inflamed rotator cuff tendons continue to get worse, and develop to fibrosis and tendonitis. This most often occurs between age 25 and 40. Conservative treatment and surgery should both be considered, depending on the severity of the patient’s condition.

Stage three: arcomioclavicular spur and rotator cuff tear. This stage occurs because of continuous mechanical disruption of the rotator cuff tendon between the arcomioclavicular and humoral head. Surgical anterior acromioplasty and rotator cuff repair is usually required.

Matthew appeared to have stage two (rotator cuff tear). In order to make a clear diagnosis of the disease, I ordered X-rays. They showed a anterior spur, which caused the impingement of the rotator cuff and the pain.

When Matthew played ball with his son, he had traumatized his shoulder, causing the rotator cuff to partially tear.

Treatment:

Western medicine is usually administered in four stages:

Nonsurgical treatment: the patient takes a course of oral prednosone or some form of non-steroid, anti-inflammatory medication.

The patient avoids strenuous activity and puts an ice pack on the injured shoulder.

Injection of a local steroid into the affected area.

Physical therapy: this can take from several weeks to a number of months. Many patients experience gradual improvement and a return to normal function.

Surgical treatment is usually indicated for full thickness or partial tears that failed to improve with conservative treatment. There are two kinds of surgical techniques.

Arthrosopic technique: two or three small puncture wounds are made and a small instrument is inserted to remove the surface of the arcomion and clean out the injured tissue of the rotator cuff.

Open technique: open surgery that cuts into the shoulder and allows direct visualization into the acromion and rotator cuff.

Matthew was offered all these options, but because of his work, he could not afford to take off time, and thus opted for a conservative treatment.

I first combined physical therapy with acupuncture, and advised him to put an ice pack on his shoulder immediately, and rest his arm as much as possible, strictly avoiding any activities that might aggravate the symptoms.

I then introduced acupuncture to decrease the pain. I used “the three famous shoulder needles” technique: Jian Qian, Jian Yu, and Jian Zhen. All of these must be inserted 2-3 inches deep into the respective anatomic points: the rotator cuff including bicepital, supraspinator tendons, and acromial bursa etc. Then, a strong electrical stimulation should be used to bring a large amount of blood flow to the shoulder and wash away the inflammation to gradually diminish the sensation of pain and improve the range of shoulder motion.

The ancillary points include LI 14 Bi Nao, SJ 5 Wai Guan, LI 4 He Gu and LI 11 Qu Chi. The patient was treated for about three months and, after passing through the acute stage, I gradually strengthened his rotator cuff muscle and after six months his shoulder had returned to normal. His range of motion also returned to normal, and there was no need for surgery.

Table 8-1

Points

Meridian/No.

Location

Function/Indication

1

Jian Qian

Extra 23

Midway between the end of the anterior axillary fold and LI 15, Jian Yu

Pain in the shoulder and arm, paralysis of the upper extremities

2

Jian Yu

LI 15

Antero-inferior to the acromion, on the upper portion of m. deltoideus. When the arm is in full abduction, the point is in the depression appearing at the anterior border of the acromioclavicular joint

Pain in the shoulder and arm, motor impairment of the upper extremities, rubella, scrofula

3

Jian Zhen

SI 9

Posterior and inferior to the shoulder joint. When the arm is adducted, the point is 1 inch above the posterior end of the axillary fold

Pain in the scapular region, motor impairment of the hand and arm

4

Bi Nao

LI 14

On the line joining Qu Chi (LI 11) and Jian Yu (LI 15), 7 inches above Qu Chi (LI 11), on the radial side of the humerus, superior to the lower end of the m. deltoideus

Pain in the shoulder and arm, rigidity of the neck, scrofula.

5

Wai Guan

SJ 5

See table 5-1/Pic 5-3

See table 5-1

6

He Gu

LI 4

See table 3-1/Pic 3-4

See table 3-1

7

Qu Chi

LI11

See table 4-1/Pic 4-2

See table 4-1

Pic 8-1

Tips for both acupuncturists and patients:

1. If the patient has rotator cuff tendonitis or impingement, and is less than 25 years old and in the acute stage, an ice pack on the shoulder to decrease both the edema and inflammation, followed by acupuncture, is usually a sufficient cure.

2. If the patient has stage two fibrosis and tendonitis, and is between the ages of 25 and 40, acupuncture should start as soon as possible, as described above. This is usually sufficient treatment at this stage.

3. If the patient has stage three acromioclavicular spur and rotator cuff tear, and is over the age of 40, doctors should cautiously examine treatment options. The patient should have an X-ray and MRI without contrast to discover if the patient has a partial or complete tear, and he should consult an orthopedic surgeon to see if surgery is necessary. If the patient is young and the injury is related to sports, the torn rotator cuff should be sutured as soon as possible in order to accelerate a complete recovery.